- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.48 / $126.48 / $126.48
| Facility | | $126.48 | $126.48 | $126.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.48 / $126.48 / $169.87
| Professional | | $126.48 | $126.48 | $169.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.00 / $188.00 / $211.25
| Professional | | $188.00 | $188.00 | $211.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.03 / $129.03 / $129.03
| Professional | | $129.03 | $129.03 | $129.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.87 / $200.87 / $613.45
| Professional | | $200.87 | $200.87 | $613.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.78 / $154.18 / $231.65
| Professional | | $102.78 | $154.18 | $231.65 |